polio updatesss

National Polio Surveillance Project: GoI & WHO

Workshop on

“Polio updates & End game strategies”

Organized by

Community Medicine Department,

GMERS Medical College, Sola,

in collaboration with

NPSP (WHO), Gandhinagar 16th April, 2013


Polio update, AFP SurveillancePolio update, AFP Surveillance End game strategy

Dr. Anish Sinha State Surveillance Medical Officer

World Health OrganizationNational Polio Surveillance Project, India,

Gandhinagar.


Contents….

• Global/ National / State update.

• Epidemiology of polio.

• AFP Surveillance.

• SIAs (NIDs / SNIDs).

• Certification of Polio eradication.

• End game strategy.


1988

350 000 cases

125 countries

Areas with Active Polio Transmission

2012

223 cases

5 countries


Rukhsar Khatoon last case of WPV detected in India (Jan 2011), her mother Shabida Bibi in Shahapar village, WB


India• India last polio case on 13th Jan.2011

• Removed from list of ENDEMIC Countries list in Feb.2012

Looking forward for Certification (SEAR) in Feb.2014


Nigeria(122) Pakistan

(58)

Afghanistan(37)

ONLY THREE ENDEMIC COUNTRIES

CHAD 5 WPV1 (IMPORTATION)Niger 1WPV1

Global Polio updates 2012

Till 9 Apr 13 – 18 cases (Nig-11, Pak-6, Afg-1)


WPV transmission from Northern Sindh, Pakistan to Greater Cairo (environmental sample +ve), Egypt

Importation of WPV 2013 -, Egypt - polio free since 2004.


WPV cases, India

P1 wild P3 wild

No case since Jan 2011

* data as on 12 April 2013

P2 wild

1600

1934


State P2West Bengal 1Total 1

VDPVState P1 P3 Total

West Bengal 1 0 1

Total 1 0 1

WPVs

Location of wild poliovirus and VDPV cases by type, India

2011 2012 2013*

State P2

Bihar 1Total 1

VDPV



Last wild poliovirus cases by type, India

WPV2 24/10/1999

Aligarh (UP)

WPV1 13/01/2011

Howrah (WB)

WPV3 22/10/2010Pakur (JH)


National Polio Surveillance Project: GoI & WHOWild poliovirus type 1

Wild poliovirus type 3

Negative for wild poliovirus

Scheduled but sample not collectedX

Sampling not scheduled

Wild poliovirus detected in sewage samples, 2010 – 2011

2010Mumbai

Delhi

2011Mumbai

Delhi

Patna

Kolkata

Week

F ward

G ward

M ward

Week

Red cross hospital

Bhalaswa lake

Wazirpur JJ colony

Swarn cinema

Batala house (Okhla)

Sonia vihar

Nangloi

Week

Choti pahari

Dujara

Transport nagar

Week

Ward 8, MM

Ward 135, KMC

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

XX XXX

XXX

XXXXXXX

X XXXX

X XXXX

XX

X

XXX

X XXXXXX

X

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 39 4033 34 35 36 5245 46 47 48

X

49 50 5141 42 43 4437 38



Wild poliovirus type 3 Result pending

Negative for wild poliovirus Scheduled but sample not collectedX


Wild poliovirus detected in sewage samples, 2012*

Mumbai

Delhi

Patna

Kolkata

Week

F ward

G ward

M ward

Week

Red cross hospital

Bhalaswa lake

Wazirpur JJ colony

Swarn cinema


Sonia vihar

Nangloi

Week

Choti pahari

Dujara

Transport nagar

Week

Ward 8, MM

Ward 135, KMC

Ward 29, KMC

Ward 66, KMC `

49 5037 38 39 4033 34 41 42 43 44 5245 46 47 48 5135 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

X X X X

X X X X X X X X X X X



1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52




Wild poliovirus type 3 Result pending

Negative for wild poliovirus Scheduled but sample not collectedX


Wild poliovirus detected in sewage samples, 2013*


Mumbai

Delhi

Patna

Kolkata

Week

F ward

G ward

M ward

Week

Red cross hospital

Bhalaswa lake

Wazirpur JJ colony

Swarn cinema


Sonia vihar

Nangloi

Week

Choti pahari

Dujara

Transport nagar

Week

Ward 8, MM

Ward 135, KMC

Ward 29, KMC

Ward 66, KMC

49 5037 38 39 4033 34 41 42 43 44 5245 46 47 48 5135 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

49 50 51 5245 46 47 4841 42 43 4437 38 39 4033 34 35 3629 30 31 3225 26 27 2821 22 23 2417 18 19 2013 14 15 169 10 11 125 6 7 81 2 3 4

X X X X X X X X

X X X X X X X X

X X X X X X X X

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52


Progress in India–A snapshot

P1 wild P3 wild


P2 wild

1600

1934•1995: Polio SIAs (campaigns) launched

•1997: Acute Flaccid Paralysis (AFP) Surveillance initiated

•1999: Last case of Wild Polio Virus (WPV) type 2 – (U.P)

•2010: Last case of WPV type 3 - (Jharkhand)

•2011: Last case of WPV type 1 - ( West Bengal)

•2012: India removed from list of endemic countries


2005 - 1

Gujarat Wild Cases 2000-13

BAN

KTC

JMC

RJC

AML

BVC

KDA

PML

DHD

VDD

SRC

NAVDNG

AMD

AND VDC

SRN

GNR

VLD

AMC

NMDBRH

SBK

BVN

JUN

PATMSN

JMD

POR

SRT

RJT

2002 - 24

2003 - 3

2001 - 1

2004 - 0

Year - Cases 2000 - 2

2006 - 4

2007 - 1

2008 - 0

2009 - 0

2010 - 0

2011 - 02012 - 02013 - 0


Epidemiology of Polio


Polio: Epidemiology• Reservoir of infection: Man (for every clinical case,1000

sub clinical case (children) & 75 (adults)• Infective material: feces • Period of communicability: most infective 10 days before

& after onset. Host factors• Age:6 months to 3 years most common• Sex: 3:1 ---male: female• Precipitating factors: fatigue, trauma, I/M injections• Immunity : OPV (life long) Environmental factors• Rainy season (Jun – Sep), overcrowding & poor

sanitation


Paralytic Poliomyelitis• Acute onset• Fever just prior to onset of paralysis• Associated symptoms: malaise, sore throat, constipation abdominal

pain. Muscle pain• Signs of meningeal irritation, stiffness in back & neck may be present.• Progression: maximum in <4 days. starts proximally and moves distally• Involvement: asymmetrical patchy paralysis ,proximal muscle groups>

distal muscle groups• DTR: diminished• Cranial nerve involvement : uncommon• Respiratory insufficiency: life threatening, uncommon• Sensory: no lossonly way to confirm is isolation of wild virus from stool.


Strategies of Polio Eradication

1985 – Routine immunization Individual immunity

1995 – NID’s ( PPI / IPPI ) To replace wild with vaccine virus

1997 - AFP surveillance

To identify reservoir of transmission 2000 – Mopping up immunization

To eliminate last foci of transmission


AFP Surveillance


Objective of AFP surveillance

Reliably detect areas where polio transmission is occurring or likely to occur


Principle of AFP Surveillance in identifying polio cases

Identify children with the SYNDROME of Acute Flaccid Paralysis

• Acute- Sudden onset, Rapid progression

• Flaccid- Floppy/ soft & yielding to passive stretching at anytime during the illness.

• Paralysis is loss of strength of muscles,

Severe loss of motor strength is called paralysis or plegia

Paresis- less severe loss of motor strength


Definition of AFP for surveillance purposes

Sudden onset weakness & floppiness in

any part of the body in a child < 15

years of age or paralysis in a person of

any age in which polio is suspected.


Logic of AFP investigation & stool sample collection

• Sensitivity increases when all AFP cases investigated

• Testing of stools of all AFP - most valid test for identification of Polio

• ALL cases with ‘AFP’ should be reported & their stools must be tested!!

• Even if other ‘tests’ (CT scan, MRI, etc.) or additional clinical information point to other diagnoses; stools must be tested to rule out Polio


Reporting

• All AFP cases should be reported immediately

• ALL AFP cases reported within 6 months of

onset of paralysis should be investigated

• All reporting units, informers and other contacts

should continue to report AFP cases as per

existing case definition


Action when AFP is reported• FIRST – Start stool collection process• Investigate - SMO/ DIO - Confirm if AFP, if not reject

case & record the same. There is only one category of cases - AFP • Allot EPID number & Report the case as AFP• CIF & LRF should be filled. • Use the revised CIF/ Linelist form.

• Ensure that stools are transported to lab in cold chain• NPSU will Classify after lab result received• Give feedback to the source that the AFP reported was/

was not polio.• Maintain documentation at ALL levels.


Therefore…

The basic system of AFP surveillance remains

unchanged

• To enhance sensitivity, all cases of acute flaccid

paralysis should be reported & investigated

• Borderline cases should be included & stool

specimens tested


The AFP Surveillance System

Hospitals ClinicsCommunity

Investigation

Non-Polio AFP Polio AFP


When too much polio is around…..

Non-AFP cases

Polio cases

AFP cases

Borderline AFP cases

Surveillance sensitivity is

adequate enough to

detect 90% polio cases


When transmission is very low…..

Non-AFP cases

Polio cases

AFP cases

Borderline cases

Surveillance sensitivity is

not good enough &

detects only 50% polio

cases

…Sensitivity increases and leads to 100%

detection of polio cases

If borderline cases are taken &

stool specimens collected …

Remember Non AFP cases still not taken


Likely Likely to beto be AFP cases…. AFP cases….

• GBS of any variety

• Transverse myelitis

• Monoparesis

• Traumatic neuritis

• Flaccid Paraplegias

• Flaccid Quadriplegia

• Isolated bulbar paralysis

• Post-diphtheric polyneuritis

• Viral neuritis,

• Flaccid hemiplegia

• Isolated neck paralysis

• Wrist/foot drop, etc.

• Transient paresis

• Facial Palsy.


Clinical Presentation 2006 2007 2008 2009 2010

Clinical Poliomyelitis 586 (86.7) 757 (86.71) 494 (88.37) 648 (87.45) 32 (76.19)

Only H/O Paralysis 24 (2.7) 14 (1.60) 14 (2.5) 10 (1.35) 1 (2.38)

Hemiplegia 35 (5.2) 54 (6.19) 25 (4.47) 48 (6.48) 3 (7.14)

G.B.Syndrome 6 (0.9) 3 (0.34) 3 (0.54) 3 (0.40)

Traumatic Neuritis 4 (0.6) 8 (0.92) 1 (0.18) 2 (0.27)

Only Limp 4 (0.6) 1 (0.11) 0 (0) 4 (0.54)

Acute Encephalitis 3 (0.4) 3 (0.34) 4 (0.72) 1 (0.13)

Isolated Facial Palsy 3 (0.4) 19 (2.18) 10 (1.79) 14 (1.89) 4 (9.52)

Isolated Neck Flop 4 (0.6) 5 (0.57) 4 (0.72) 4 (0.54)

Post Diptheric Polyneuritis

0 (0) 2 (0.23) 0 (0) 1 (0.13)

Others 7 (1.0) 7 (0.80) 4 (0.72) 6 (0.81) 2 (4.76)

Total 676 873 559 741 42

Analysis of initial clinical presentation of WPV 2006 - 10


STOOL COLLECTION, STORAGE ,

TRANSPORT.• Adequate Stool.

– 2 Specimens, 24 Hours Apart.

– 8 gms.

– Within 14 Days of Paralysis Onset & with proper Cold Chain

• Procedure.

– Errors.

– Storage(Delayed Second Sample)

• Cold Chain.

• Rectal Tube.

• Transport.(PHN & HA)

• Death of AFP Case.( Spinal Cord , Intestinal Content)


GOLD STANDARD FOR AFP SURVEILLANCE

• Non – Polio AFP Rate > 2.0

• Adequate Stool Samples > 80%

• Timeliness of Reporting > 80%


VIROLOGIC CLASSIFICATION SCHEME

NO WILD POLIOVIRUS

AFP

WILD POLIOVIRUS

INADEQUATE

STOOL SPECIMENS

TWO ADEQUATE*

STOOL SPECIMENS

NO RESIDUAL WEAKNESS

CONFIRM

COMPATIBLE

DISCARD

DISCARD

RESIDUAL WEAKNESS, DIED OR LOST TO F/U

DISCARD

EXPERT REVIEW


#

#

S

S

#S

#S

#S

###SSS

#S

#S

#S

##

SS

#S

2002 – 14 cases

2003 – 4 cases

2004 – 1 case

2005 – 7 cases

2006 – 3 cases2007 – 5 cases2008 – 1 case2009 – 1 case2010 – 1 case

2011 – 0 Case2012 – 0 Case2013 – 0 Case

Compatible Cases 2002-2013


HOT CASE• A case of AFP with any of the following set of

conditions -Age < 5 year plus H/O fever at onset plus

asymmetrical proximal paralysis.Age < 5 year with rapidly progressive paralysis

leading to bulbar involvement (cranial nerves affected) & death.

Any case which in the opinion of SMO/DIO looks like polio.


CONTACT SAMPLES

To be considered for cases fulfilling criteria like Hot cases, but adequate samples from case could not be taken


Supplementary Immunization Activities:

NIDs/ SNIDs


SIAs• NID: National Immunization Day.

- Booth Activity.- House-to house Activity.- Transit Teams.- Mobile Teams.

• SNID: Sub National Immunization Day.- Migratory SNID in Gujarat (11 districts & 5 corporations).


Continued focus on high risk areas and populations

West UP: HR blocks – 66

Bihar: HR blocks – 41

107 blocks of UP and Bihar Kosi river operational intensification

Immunization of newborns

Intense focus on migrants & mobile populations Religious congregations

8 million children in transit immunized in India each round 100,000 of these in running trains

2 million children vaccinated in congregations each year


Certification of polio eradication


Background• Certification is done for WHO Regions; not for individual

countries

• WHO Regions certified polio free:

– Americas 1994

– Western Pacific 2000

– Europe 2002

• Certification of a region is considered only when

– All countries in the area demonstrate Absence of WPV transmission for at least 3 consecutive

yearsPresence of certification standard surveillanceGlobal action plan for laboratory containment of WPV


Certification of SEAR*

* South East Asia Region of WHO

1995 2012 20131997 2011 2014

GCC formed

Feb: India will present final document

Certification of SEAR likely

2 RCCPE meetings planned

28 Aug: India presents

Preliminary Document

Dec: Special RCC Meeting for

India

Last WPV case in SEAR

SEARCCPE formed


Certification standard surveillance• Non-polio AFP rate: ≥ 2 per 100,000 population

(< 15 years) annually

• Adequate stool specimens : ≥80%

• All stool specimens tested for poliovirus at

WHO-accredited laboratory • Additional Criteria

• Investigation of AFP cases within 48 hours of initial notification: ≥80%

• Timeliness of weekly AFP surveillance reports: ≥80%


National Certification Committee for Poliomyelitis Eradication (NCCPE)

• Established in 1998 to

• Examine, assess & verify data collected by govt.

• Field visits to review evidence of interruption of

poliovirus transmission in the country

• Independent judgment of polio status

• Present country report to RCCPE**Regional Certification Commission for Poliomyelitis Eradication


• Sep12 - Jun13

• Five categories of states have been formed

NCCPE Field Visits

Category 5 states


Laboratory Containment

• Union Health Ministry already issued letter in this regard to all the States (dated 14th Feb 2013).

• National Task Force for Lab Containment of WPV formed, Health Secretary (GOI) - Chairman.

• To identify Labs, likely to store WPV – by Dec 2013.


Polio Endgame Strategy


Context• No WPV2 in India since 1999

• tOPV used in RI and during NIDs

• bOPV used in most SNIDs since Jan 2010

• Areas/ populations with low routine immunization coverage

• All cVDPVs in India due to type 2 in setting of low immunity to type 2


cVDPV cases, India 2009-2011

•cVDPV cases detected in 2009-10

•100% due to type 2

DistrictType 2

2009 2010 2011

Badaun 3 0 0

Bulandshahar

2 0 0

Ghaziabad 0 1 0

Meerut 2 0 0

Moradabad 2 0 0

Pilibhit 4 0 0

Shahjahanpur

2 1 0

Total 15 2 0


Trends in Seroprevalence Against PoliovirusResults from Different Serosurveys

Moradabad Nov 2007(N=121)

AFP cases UPNov 08 –

mid 09(169)

Moradabad May 2009(N=534)

UP & BiharAug 2010(N=1280)

UP & BiharAug 2011(N=1246)

Age 6-7 mo 6-11 mo 6-7 mo 6-7 mo 6-11 mo

Type 1 78% 96.5% 99% 98% 98.5%

Type 2 56% 33.7% 75% 65% 85%

Type 3 69% 42.6% 49% 77% 88.2%

High immunity levels sustained for P1 since 2009Increasing trend in immunity level for P3 in 2010-11


Managing the risk of VDPVs


Preparing for the polio endgame

• A tOPV- bOPV switch globally (~2014/2015)

• Use of IPV in conjunction with OPV (?)

• Eventual cessation of all OPV use globally at

some point in the future (e.g. 2017-18 period).

• Support research activities to generate evidence to

guide decision making


Pre-switch boosting of type 2 immunity

• Switch soon after tOPV NIDs

• Improve RI, particularly DTP3 and OPV3 coverage

• Adding a dose of IPV in RI for infants prior to switch


Conclusions• India can be in a position to move ahead with polio

endgame strategy• Careful planning and consideration of risks required

before implementation• Earliest possible timing for tOPV-bOPV switch: Qtr.1

2014• Lessons from tOPV-bOPV switch significant for

subsequent withdrawal of all OPV from programme


Thank you

polio updatesss

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